Bipolar stimulator probes attachable to an electrical stimulator device or an electromyographic (EMG) device are commercially available for surface stimulation of peripheral nerves. Such apparatus provide both a stimulation electrode and a reference electrode on a single device. There are also bipolar bar electrode configurations, and sets of separate (individual) electrodes, for surface recording of nerve and muscle action potentials, and that can also serve to provide electrical muscle stimulation.
These types of devices can be used in surface stimulation for eliciting muscle twitches of the type sought in a muscle pain and discomfort relieving method developed by the present inventor, referred to as Surface Applied Electrical Twitch Obtaining Intramuscular Stimulation. This methodology is described in the present inventor's U.S. patent application Ser. No. 11/470,757, entitled “Intramuscular Stimulation Therapy Using Surface-Applied Localized Electrical Stimulation,” filed Sep. 6, 2006, which is hereby incorporated by reference in its entirety. Treatments utilizing the methodology are clinically offered by the present inventor, and assignee Jus-Jas, LLC, under the service mark eToims®. For convenience, this service mark will be used herein to refer to this methodology as offered by the inventor and/or Jus-Jas, LLC or its affiliates. This technique involves the provision of brief electrical stimulation at multiple motor end-plate zones in many muscles. It is important that the stimulation method be “user friendly,” to both patient and treating clinician. That is, the stimulation should not cause significant additional discomfort to the patient and the method should be easy to apply for the clinician.
Commercially available standard bipolar stimulating probes have an inter-probe distance of 2 cm or less between the active and reference electrodes. This type of bipolar stimulation induces significant stimulation pain making it undesirable for use in the eToims® procedure. In addition, due to the close proximity of the active and reference electrodes, twitches that may be elicited with such devices are small and have low forces, and therefore do not provide significant pain relieving effects. Similarly, as mentioned, surface electrodes that can be used for recording as well as stimulation purposes are available in the form of a bar electrode pair. Such devices have an inter-electrode distance of about 3-4 cm, and thus the problem of inducing stimulation pain arises if these devices are used to perform eToims®. Stimulation/recording electrodes are also available as separate (individual) electrodes. However, separate individual electrodes are less than ideal for use in the eToims® procedure, since both the active and reference electrodes have to be moved in bi-manual fashion to multiple stimulus and reference sites, thus slowing down and encumbering the eToims® procedure and making the procedure more difficult for the clinician.
The performance of eToims® using this inventor's bipolar probe with widely spaced electrodes (described in U.S. application Ser. No. 11/830,235, filed Jul. 30, 2007, published on Jan. 31, 2008, under No. 2008-0027508 A1, hereby incorporated by reference in its entirety) advantageously facilitates a methodology wherein: (1) the stimulation does not induce additional pain to a patient who is already in pain, or cause new pain to a client who has no pain but wants to obtain a relaxing massage effect to relieve muscle tightness/discomfort; and (2) the stimulation is beneficially able to penetrate the deeply situated motor endplate zones or neuromuscular junctions. In eToims®, it is desirable that the stimulation be carefully titrated between the patient's tolerance to pain and the clinician's need for using the stimulus strength and pulse width most appropriate to be able to penetrate through skin, subcutaneous tissue and the muscles, to stimulate deep motor endplate zones. In situations where the patient is unable to tolerate stimulation pain, the stimulus parameters often have to be reduced to make the treatment more comfortable for the patient. Often when the stimulus has to be reduced enough not to cause pain to the patient, only the superficial motor endplate zones can be stimulated. For those with discomfort/tightness or mild acute pain, this superficial muscle relaxation caused by the tissue mobilization effect of eToims® provides a scientific massage effect. This scientific massage effect can be sufficient to relieve discomfort or subclinical pain more significantly than that which can be obtained with manual massages. However, this precludes the deep tissue mobilization effects needed to produce neuromuscular pain relief for those patients with significant chronic pain.
A hallmark of eToims® is the ability to achieve elicitation of twitches that will move an associated joint in the direction of action of the stimulated muscle. These twitches have such a strong recoil effect on the hand holding onto the probe that the probe may be lifted or displaced off the surface of the stimulated muscle. The best pain relieving results with eToims® occurs with the elicitation of these large force twitches, qualitatively termed by the inventor as “movers”. To achieve optimal pain relieving results during an eToims® session, it is important to quickly locate and stimulate the irritable motor endplate zones that elicit the most forceful twitches (movers) in as many muscles as needed to reduce the pain/discomfort symptoms.
If the muscle tissues are tight because of underlying pain or if the patient voluntarily or involuntarily tenses and contracts his/her muscles because of stimulation pain, electrical stimulation of the deep motor endplate zones is difficult since insufficient electricity will reach the deeper layers of the muscles. This is due to the electricity being filtered or buffered by the overlying tight muscle tissues. In such situations, the twitches elicited may not have sufficient force to move the joint in the direction of action of the treated muscle but still may have capacity to rock or shake the joint, qualitatively termed by the inventor as “shakers”. These types of twitches that rock or shake the joint (shakers), will have a recoil effect on the clinician's hand holding onto the probe, though not as strong as those twitches that can move the joint. This recoil effect on the hand holding onto the probe differentiates twitch forces that shake the joint from those twitches which do not have joint play, i.e. no joint movements or shaking effect. The twitches that have ability to shake the joint also have pain relieving therapeutic effects but the pain relieving effects are sub-optimal compared to the twitches that move the joint in the direction of action of the stimulated muscle. The twitches that do not have any recoil effect on the hand holding onto the probe and thus have no joint play arise from stimulation of the superficial motor end-plate zones. These types of weak twitches are adequate to relieve muscle discomfort/tightness and/or even mild acute pain due to the stretching effects on the surface muscles in spasm. However, the weak twitches are not strong enough to stretch deep, tight and shortened muscles in strong spasm closest to the bone and joint to relieve deep neuromuscular pain/tightness as that which occurs in those who have chronic pain.
The mechanism which underlies pain relief related to the force of the twitches can be explained by the fact that damaged motor end plate zones or neuromuscular junctions trigger muscles to spasm and become tight producing pain through a vice-like effect on the pain sensitive intramuscular blood vessels and nerves as well as a strong traction effect on underlying pain sensitive bone and joints. Unlike other methods, eToims® targets pain and discomfort at these damaged points, releasing muscle tightness and spasm. eToims® stimulates deep motor endplate zones causing deep tight tissue within muscles to contract or twitch with surface applied electrical stimulation. These twitches are immediately accompanied by muscle relaxation which release tightness and increase intramuscular blood flow to restore circulation to damaged motor endplate zones allowing them to heal immediately in acute cases and over time with continued regular eToims® in chronic cases. With regular eToims® treatments, injured or tight muscles can properly heal, leading patients to enjoy an active daily life with continued improvement in range of body motion, accompanied by a decrease in pain and discomfort thus increasing their quality of life. In the process mentioned above, when muscle spasm is released, internal muscle stretching occurs. eToims® can be differentiated from other types of invasive and non-invasive neuromuscular stimulation by this ability to perform effective deep internal muscle stretching from stimulation of deep motor endplate zones (also known as neuromuscular junctions or trigger points).
For eToims® to be able to optimally achieve deep motor endplate zone stimulation without undue additional pain to the patient, the conducting properties of the electrode are important. If the electrode is rigid or inflexible and if it does not conform to uneven skin surfaces, there will be uneven dispersion of electricity and stimulation received by the deep motor end plate zones will be inconsistent leading to unpredictable pain relieving results. Also, the uneven electrical dispersion can cause stimulation pain to the patient. If the conduction property of the electrode is poor, stimulation of the deep motor endplates is often not achievable. On the other hand, even though deep stimulation is possible by increasing the stimulus strength and pulse width, if it is at the expense of introducing too much stimulation discomfort to the patient, patients will voluntarily and/or involuntarily tighten up the muscles defeating the purpose of deep stimulation. In fact the patient may even ask for cessation or termination of the stimulation session and not return for further eToims® sessions. Another alternative is to give prescription pain relieving medications half-hour to one hour before the stimulation so that the patient can tolerate the treatment. This is disfavored by this inventor, however, because it will then limit the treatment to only patients who are willing to take the medications to undergo the treatment. The potential treatment pain will also deter those healthy clients from trying eToims® as a scientific massage to relieve muscle tightness and discomfort. A goal of this inventor's implementation of eToims® is to encompass such generally healthy clientele and patients within the community of individuals undergoing regular treatment regimens over the long term, so that they can continue to enjoy an increase in, and prolongation of, quality of life.
eToims® results are best when applied prior to developing pain or as soon as possible after development of acute pain, preferably within 24 hours, since the muscles are not as tight and eToims® has potential to effectively relieve acute pain completely, even with one session or a few sessions, and thus prevent the development of chronic pain. Through experiencing pain relief with eToims®, and by reducing the stimulation discomfort during eToims®, patients and healthy clientele can be encouraged to return for further treatments on a regular basis for continuing benefits that the treatments can provide. Using effective and comfortable stimulation of deep motor endplate zones also has the potential to prevent healthy clientele, and those suffering from acute and chronic pain, from experiencing sudden pain onset, by keeping the muscles relaxed. This is due to the ability of eToims® to provide exercise and stretch effects to muscles which increases the blood supply to the neuromuscular junctions allowing them to heal rapidly on injury. eToims® can thus increase the safety margin that neuromuscular junctions have from compromise in situations of sudden or repetitive trauma that occurs with activities of daily living, sports, work, recreational activities, etc., in healthy people as well as those suffering from acute and chronic pain.
For electrical stimulation purposes, the common electrodes used for the nerve conduction velocity determination portion of electrodiagnosis are saline soaked small, disposable felt pads of about 7 mm in diameter and about 5 mm in height. FIG. 1 shows a bipolar probe 1 with widely spaced electrodes, constructed in accordance with the inventor's previously referenced U.S. application Ser. No. 11/830,235. The present inventor has used felt plugs 3, 5 of a diameter appropriate to fit receptacles 7, 9 for electrodes provided on the stems or arms 11, 13. Such a tool 1, equipped with felt plugs 3, 5 positioned in the cylindrical cup-like receptacles 7, 9 thereof, is shown in FIG. 1, in use applied against a patient's skin/flesh 14. FIG. 2 shows the tool grasped but out of contact with a patient. The same tool 1, with the felt plugs removed from the receptacles 7, 9, is shown in FIG. 3, thus revealing circular electrode plates 15 and 17 inset slightly at the ends of the tool stems 11, 13. It will be appreciated that one of the stems (stem 11) of the tool 1 is fixable in various positions along a slot 19 (visible in FIG. 3) extending along a tubular combination handle and cross-connection member 21, to provide different relatively wide spacings of the electrodes. Also visible in the figures, protruding laterally from opposite sides of the tubular cross-connection member 21, are finger operable wheels 23, 25 which control the pulse duration (ms) and stimulus strength (mamps). At the top, between the wheels, is a push-button 27 serving as a stimulation initiating trigger switch (best seen in FIGS. 2 and 4).
The felt plugs 3, 5 themselves (e.g., SAE felt specifications Grade #F-5 at 12.24 lbs per sq.yd, 1″ to Grade #F-10 at 8.48 pounds per square yard, 1″, F-10 preferable since it is softer and easier to soak through) are shown in FIG. 5. These felt plugs 3, 5, having a diameter of about 1″ and a thickness of about ½″, are pre-soaked, preferably overnight in plain water or 10% saline, to facilitate conduction. These felt plugs 3, 5 fit the probe receptacles 7, 9 snugly needing no adhesive taping to hold it in place. However during eToims®, the patient contact surfaces of the felt plugs 3, 5 dry easily making the stimulation sharp and painful for the patient. There is thus a need for frequent re-wetting of the patient contact surface of the felt plugs 3, 5 to reduce the pain during stimulation, which is time-consuming to the clinician during the eToims® procedure. Frequent wetting of the patient contact surface of the electrode with saline solution to aid the stimulation leaves dried salt all over the stimulation sites such that the dried salt has to be cleaned off from the patient's skin at the end of the procedure, adding more time to the procedure. Additionally, felt is abrasive and can produce allergic reactions or rash to those susceptible, and felt is best not used for direct contact against skin for surface electrical stimulation purposes especially where repetitive and repeated stimulation is needed. The felt plugs 3, 5 are also relatively inflexible and do not conform to the shape of uneven skin surfaces making the dispersal of electricity into the tissue uneven. This contributes to unnecessary pain during electrical stimulation.